ClientId:
ElectionId:
Name:
Year of Birth: Voter Id:
Address:
Email:
Phone Number:
Address to Mail Ballot:
Additional Information and Instructions:
PERMANENT VOTE BY MAIL
Please add me to the Permanent Vote By Mail List
I certify that I reside at the address specified above, in the stated county and in the precinct in which my residence is located, that I have lived at such address for 30 days or more preceding this election, that I am lawfully entitled to vote in such precinct at said election to be held therein, and that I wish to vote by mail ballot.
CHECK BOX TO ACCEPT...You must accept before clicking Submit. This form is for web site submittal and cannot be mailed. By clicking Submit I certify that the statements set forth in this application are true and correct under penalties as provided by law pursuant to 10 ILCS 5/29-10.
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